Contents

Key Information

What should I do?

If you think you have this condition you should see a doctor within 1 week.

How is it diagnosed?

Most cases of subjective vertigo are diagnosed by your doctor after taking a full history of your symptoms and performing a physical examination, including looking into your ear and examining your eye movements. If the diagnosis is not certain, you might be referred to a specialist doctor for further hearing tests, balance tests or scans.

What is the treatment?

The treatment of vertigo depends on the severity and the cause of your symptoms.

Medicines such as prochlorperazine or antihistamines may be helpful in you are experiencing severe nausea and vomiting.

Your doctor might recommend that you lie still in a dark room to help with the nausea attacks.

If the vertigo is caused by a viral infection, this will settle on its own after a couple of weeks.

When to worry?

If your vertigo does not improve after 1 week, or if you have any of the following symptoms, please see a doctor immediately:

Introduction

Vertigo is a symptom, rather than a condition itself. It's the sensation that you, or the environment around you, is moving or spinning.

This feeling may be barely noticeable, or it may be so severe that you find it difficult to keep your balance and do everyday tasks.

Attacks of vertigo can develop suddenly and last for a few seconds, or they may last much longer. If you have severe vertigo, your symptoms may be constant and last for several days, making normal life very difficult.

Causes of vertigo

Vertigo is a symptom of several different conditions. There are two types of vertigo, known as peripheral and central, depending on the cause.

Peripheral vertigo

Peripheral vertigo is the most common type, often caused by a problem with the balance mechanisms of the inner ear. The most common causes include:

benign paroxysmal positional vertigo (BPPV)

head injury

labyrinthitis

vestibular neuronitis

Ménière's disease

taking certain types of medication

These causes are explained in more detail below.

Benign paroxysmal positional vertigo (BPPV)

This is one of the most common causes of vertigo. It can occur during specific head movements, while standing up or bending over, crossing the road, or turning in bed.

BPPV involves short, intense, recurrent attacks of vertigo (usually lasting a few seconds to a few minutes). It is often accompanied by nausea, although vomiting is rare. You may also experience your eyes briefly moving uncontrollably (nystagmus).

Lightheadedness and a loss of balance can last for several minutes or hours after the attack.

BPPV is thought to be caused by small fragments of debris (calcium carbonate crystals), which break off from the lining of the channels in your inner ear. The fragments don't usually cause a problem, unless they get into one of the ear's fluid-filled canals.

When your head is still, the fragments sit at the bottom of the canal. However, certain head movements cause them to be swept along the fluid-filled canal, which sends confusing messages to your brain, causing vertigo.

BPPV usually affects older people, with most cases occurring in people older than 50 years of age.

BPPV may occur for no apparent reason, or it may develop after:

an ear infection

ear surgery

a head injury

prolonged bed rest – for example, while recovering from an illness

Head injury

Vertigo can sometimes develop after a head injury. If you have symptoms of dizziness or vertigo following a head injury, seek medical attention.

Labyrinthitis

Labyrinthitis is an inner ear infection that causes a structure deep inside your ear (the labyrinth) to become inflamed. The labyrinth is a maze of fluid-filled channels that control hearing and balance.

When the labyrinth becomes inflamed, the information it sends to your brain is different from the information sent from your unaffected ear and your eyes. These conflicting signals cause vertigo and dizziness.

Labyrinthitis is usually caused by a viral infection, such as the common cold or flu , which spreads to the labyrinth. Less commonly, it's caused by a bacterial infection.

Vertigo caused by labyrinthitis may be accompanied by nausea, vomiting, hearing loss , tinnitus and sometimes a high temperature and ear pain.

Vestibular neuronitis

Vestibular neuronitis, also known as vestibular neuritis, is an inner ear condition that causes inflammation of the nerve connecting the labyrinth to the brain. In some cases, the labyrinth itself can also be inflamed.

The condition is usually caused by a viral infection. It usually comes on suddenly and can cause other symptoms, such as unsteadiness, nausea (feeling sick) and vomiting (being sick). You won't normally have any hearing problems.

It usually lasts a few hours or days, but it may take three to six weeks to settle completely.

Ménière's disease

Severe vertigo is sometimes caused by a rare condition that affects the inner ear, called Ménière's disease . This can cause vertigo, as well as hearing loss, tinnitus and aural fullness (a feeling of pressure in your ear).

If you have Ménière's disease, you may experience sudden attacks of vertigo that last for hours or days. The attacks often cause nausea and vomiting.

The cause is unknown, but symptoms can be controlled by diet and medication. Rarely, you may need further treatment in the form of surgery.

Medication

Vertigo may occur as a side effect of some types of medication. Check the patient information leaflet that comes with your medicine to see if vertigo is listed as a possible side effect.

Don't stop taking prescribed medication without your doctor's advice, but speak to your doctor if you're worried about the side effects. They may be able to prescribe an alternative medication.

Central vertigo

Central vertigo is caused by problems in part of your brain, such as the cerebellum (located at the bottom of the brain) or the brainstem (the lower part of the brain that's connected to the spinal cord). Causes of central vertigo include:

migraines – a severe headache that's usually felt as a throbbing pain at the front or on one side of your head, which is especially common in younger people

multiple sclerosis – a condition that affects the central nervous system (the brain and spinal cord)

acoustic neuroma – a rare, non-cancerous (benign) brain tumour that grows on the acoustic nerve, which is the nerve that helps to control hearing and balance

Diagnosing vertigo

Your doctor will ask you about your symptoms and carry out some simple tests to help differentiate between vertigo and general dizziness.

Your doctor will ask about your symptoms and carry out some simple tests to help them make an accurate diagnosis.

In some cases, you may be referred for some further tests.

Important questions

Your doctor will first want to know:

details of the first episode of your symptoms and what they were – for example, whether you felt lightheaded or if your surroundings were spinning

if you also experience other symptoms – such as hearing loss, tinnitus, nausea, vomiting or fullness in the ear

how often your symptoms occur and how long they last for

if your symptoms are affecting your daily activities – for example, whether you're unable to walk during an episode of vertigo

whether anything triggers your symptoms or makes them worse, such as moving your head in a particular direction

what makes your symptoms better

Physical examination

Your doctor may also carry out a physical examination to check for signs of conditions that may be causing your vertigo. This could include looking inside your ears and checking your eyes for signs of uncontrollable movement (nystagmus).

Your doctor may check your balance or try to recreate your symptoms by asking you to move quickly from a sitting to a lying position.

Further tests

Depending on your symptoms, your doctor may refer you to a hospital or specialist for further tests.

Hearing tests

If you have tinnitus (ringing in your ears) or hearing loss , your doctor may refer you to an ear, nose and throat (ENT) specialist, who can carry out some hearing tests.

These may include:

an audiometry test – a machine called an audiometer produces sounds of different volume and pitch. You listen to the sounds through headphones and signal when you hear a sound, either by raising your hand or pressing a button.

tuning fork test – a tuning fork produces sound waves at a fixed pitch when it's gently tapped. The tester will tap the tuning fork before holding it at each side of your head.

Videonystagmography

Videonystagmography (VNG) is sometimes used to check for signs of nystagmus in more detail. Nystagmus can indicate a problem with the organs that help you to balance.

During this test, special goggles are placed over your eyes and you'll be asked to look at various still and moving targets. The goggles are fitted with a video camera to record the movements of your eyes.

Electronystagmography may also be used, where electrodes are placed around the eye instead of goggles.

Caloric testing

A caloric test involves running warm or cool water or air into your ear for about 30 seconds. The change in temperature stimulates the balance organ in the ear, allowing the specialist to check how well it's working.

This test isn't painful, although it's normal to feel dizzy during the test. This can sometimes continue for a few minutes afterwards.

Posturography

A machine to test your balance may be used to give valuable information about how you are using your vision, proprioception (sensations from your feet and joints) and the input from your ear to maintain balance. This may help to plan your rehabilitation and monitor your treatment.

Scans

In some cases, a scan of your head may be used to look for the cause of your vertigo, such as an acoustic neuroma (a non-cancerous brain tumour).

Labyrinthitis

Labyrinthitis is an inner ear infection that causes the labyrinth (a delicate structure deep inside your ear) to become inflamed. It's usually caused by a viral infection and clears up on its own without treatment. In rare cases, where labyrinthitis is caused by a bacterial infection,antibiotics may be prescribed.

If you've experienced any hearing loss, your doctor may refer you to an ear, nose and throat (ENT) specialist or an audiovestibular physician. This is a doctor who specialises in hearing and balance disorders. You may need emergency treatment to restore your hearing.

Labyrinthitis may also be treated with vestibular rehabilitation – also called vestibular rehabilitation training or VRT (see below).

Vestibular neuronitis

Vestibular neuronitis, also known as vestibular neuritis, is inflammation of the vestibular nerve (one of the nerves in your ear that's used for balance). It's usually caused by a viral infection.

The symptoms of vestibular neuronitis often get better without treatment over several weeks. However, you may need to rest in bed if your symptoms are severe. See your doctor if your symptoms get worse or don't start to improve after a week.

You may find your balance is particularly affected if you:

drink alcohol

are tired

have another illness

Avoiding these can help to improve your condition.

Vestibular neuronitis can also be treated with vestibular rehabilitation and medication.

Benign paroxysmal positional vertigo (BPPV)

Like vestibular neuronitis, benign paroxysmal positional vertigo (BPPV) often clears up without treatment after several weeks or months. It's thought that the small fragments of debris in the ear canal that cause vertigo either dissolve or become lodged in a place where they no longer cause symptoms. BPPV can sometimes return.

Until the symptoms disappear or the condition is treated, you should:

get out of bed slowly

avoid activities that involve looking upwards, such as painting and decorating or looking for something on a high shelf

BPPV can be treated using a procedure called the Epley manoeuvre.

The Epley manoeuvre

The Epley manoeuvre involves performing four separate head movements to move the fragments that cause vertigo to a place where they no longer cause symptoms. Each head position is held for at least 30 seconds. You may experience some vertigo during the movements.

Your symptoms should improve shortly after the Epley manoeuvre is performed, although it may take up to two weeks for a complete recovery. Return to your doctor if your symptoms haven't improved after four weeks. The Epley manoeuvre isn't usually a long-term cure and may need to be repeated.

Brandt-Daroff exercises

If the Epley manoeuvre doesn't work, or if it's not suitable – for example, because you have neck or back problems – you can also try Brandt-Daroff exercises. These are a series of movements you can do unsupervised at home.

Your doctor will need to teach you how to do the exercises. You repeat them three or four times a day for two days in a row. Your symptoms may improve for up to two weeks.

Referral to a specialist

Your doctor may refer you to a specialist, such as an ear, nose and throat (ENT) specialist if:

the Epley manoeuvre doesn't work or can't be performed

you still have symptoms after four weeks

you have unusual signs or symptoms

In rare cases, where the symptoms of vertigo last for months or years, surgery may be recommended. This may involve blocking one of the fluid-filled canals in your ear. Your ENT specialist can give more advice on this.

Ménière's disease

If your vertigo is caused by Ménière's disease, there are a number of treatment options for both the vertigo and other symptoms caused by the condition.

Possible treatments for Ménière's disease include:

dietary advice – particularly a low-salt diet

medication to treat attacks of Ménière's disease

medication to prevent attacks of Ménière's disease

treatment for tinnitus (ringing in your ears) – such as sound therapy, which works by reducing the difference between tinnitus sounds and background sounds, to make the tinnitus sounds less intrusive

Central vertigo

Central vertigo is caused by problems in part of your brain, such as the cerebellum (which is located at the bottom of the brain) or the brainstem (the lower part of the brain that's connected to the spinal cord).

If your doctor suspects you have central vertigo, they may organise a scan or refer you to a hospital specialist, such as a neurologist or an ENT (ear, nose and throat specialist) or audiovestibular physician.

Treating your migraine should relieve your vertigo if it's caused by a migraine.

Vertigo with an unknown cause

If the cause of your vertigo is unknown, you may be admitted to hospital if:

you have severe nausea and vomiting, and can't keep fluids down

your vertigo comes on suddenly and wasn't caused by you changing position

you possibly have central vertigo

you have sudden hearing loss, but it's not thought to be Ménière's disease

Alternatively, you may be referred to a specialist, such as:

a neurologist – a specialist in treating conditions that affect the nervous system

an ENT specialist – a specialist in conditions that affect the ear, nose or throat

an audiovestibular physician – a specialist in hearing and balance disorders

While waiting to see a specialist, you may be treated with medication.

Vestibular rehabilitation

Vestibular rehabilitation, also called vestibular rehabilitation training or VRT, is a form of "brain retraining". It involves carrying out a special programme of exercises that encourage your brain to adapt to the abnormal messages sent from your ears.

During VRT, you keep moving despite feelings of dizziness and vertigo. Your brain should eventually learn to rely on the signals coming from the rest of your body, such as your eyes and legs, rather than the confusing signals coming from your inner ear. By relying on other signals, your brain minimises any dizziness and helps you to maintain your balance.

An audiologist (hearing specialist) or a physiotherapist may provide VRT. Your doctor may be able to refer you for VRT, although it depends on availability in your area.

In some cases, it may be possible to use VRT without specialist help. Research has shown that people with some types of vertigo can improve their symptoms using a self-help VRT booklet. However, you should discuss this with your doctor first. If it's likely to be useful, you can download a copy of this booklet from the Ménière's society.

Medicines

Medication can be used to treat episodes of vertigo caused by vestibular neuronitis or Ménière's disease. It may also be used for central vertigo or vertigo with an unknown cause.

The medicines are usually prescribed for 3 to 14 days, depending on which condition they're for. The two medicines that are usually prescribed are:

prochlorperazine

antihistamines

If these medicines are successful in treating your symptoms, you may be given a supply to keep at home, so you can take them the next time you have an episode of vertigo.

In some cases you may be advised to take long-term medication, such as betahistine, for conditions like Ménière's disease.

Prochlorperazine

Prochlorperazine can help relieve severe nausea and vomiting associated with vertigo. It works by blocking the effect of a chemical in the brain called dopamine.

Prochlorperazine can cause side effects, including tremors (shaking) and abnormal or involuntary body and facial movements.

It can also make some people feel sleepy. For the full list of possible side effects, check the patient information leaflet that comes with your medicine.

Antihistamines

Antihistamines can be used to help relieve less severe nausea, vomiting and vertigo symptoms. They work by blocking the effects of a chemical called histamine.

Possible antihistamines that may be prescribed include:

cinnarizine

cyclizine

promethazine teoclate

Like prochlorperazine, antihistamines can also make you feel sleepy. Headaches and an upset stomach are also possible side effects. Check the patient information leaflet that comes with your medicine for the full list of possible side effects.

A medication called betahistine works in a similar way to antihistamines. It has been used to treat Ménière's disease and may also be used for other balance problems. It may have to be taken for a long period of time. The beneficial effects vary from person to person.

Safety

If you have vertigo, there are some safety issues to consider. For example: